THE 'VOICE OF CARE': IMPLICATIONS FOR BIOETHICAL EDUCATION

ALISAL.CARSE

THE 'VOICE OF CARE':IMPLICATIONS FOR BIOETHICAL EDUCATION

ABSTRACT. This paper examines the 'justice' and 'care' orientations in ethicaltheory as characterized in Carol Gilligan's research on moral development andthe philosophical work it has inspired. Focus is placed on challenges to thejustice orientation - in particular, to the construal of impartiality as the mark ofthe moral point of view, to the conception of moral judgment as essentiallyprinciple-driven and dispassionate, and to models of moral responsibilityemphasizing norms of formal equality and reciprocity. Suggestions are madeabout the implications of these challenges, and of the care orientation in ethics,for the ethical theory taught, the issues addressed, and the skills and sensitivitiesencouraged through bioethical education.

Key Words: bioethical education, ethics of care, impartiality, moral judgment,moral psychology

INTRODUCTION

When Carol Gilligan published In a Different Voice in 1982, sheclaimed to hear a 'distinct moral voice7 in the reflections of thewomen subjects she interviewed for her research on moraldevelopment. Gilligan dubbed this 'voice' the 'voice of care' andcontrasted it with the 'voice of justice' expressed in standardethical theories rooted in Kant and the contractarians. Gilligan'sresearch was designed in part as a corrective to the research ofPiaget (1932) and Kohlberg (1981, 1984), whose studies of moraldevelopment initially excluded women, and later found women tobe 'less developed' morally than men and who, in their research,equated morality with the 'justice' approach simpliciter. Gilligan'sresearch and the work it has inspired in psychology andphilosophy have given rise to a set of challenges, both to orthodoxtheories of moral development and to dominant strains in ethicaltheory. I want to examine and motivate a number of those chal-lenges to ethical theory and to identify their implications forbioethics and education.1

Alisa L. Carse, Philosophy Department, Georgetown University, Washington, DC20057, U.S.A.

The Journal of Medicine and Philosophy 16:5-28,1991.© 1991 Kluwer Academic Publishers. Printed in the Netherlands.

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6 Alisa L. Corse

'JUSTICE', 'CARE', AND GENDER

It is most helpful to understand the two moral 'voices7 as distinctorientations within morality. These orientations are distinguishedby differences in the reasoning strategies employed and the moralthemes emphasized in the interpretation and resolution of moralproblems; they represent distinct moral sensibilities and "differentmoral concerns" (Gilligan, 1987, pp. 22-23; Gilligan et ah, 1988,p. 82).

According to Gilligan, the justice orientation construes themoral point of view as an impartial point of view, understandsparticular moral judgments as derived from abstract and univer-sal principles, sees moral judgment as essentially dispassionaterather than passionate, and emphasizes individual rights andnorms of formal equality and reciprocity in modelling our moralrelationships. By contrast, the care orientation rejects impartialityas an essential mark of the moral, understands moral judgmentsas situation-attuned perceptions sensitive to others' needs and tothe dynamics of particular relationships, construes moralreasoning as involving empathy and concern, and emphasizesnorms of responsiveness and responsibility in our relationshipswith others. Whereas we are, on the justice orientation, viewed asindividuals first, and in relationship to each other only secon-darily, through choice, we are, on the care orientation, understoodas essentially in relationship, though no single kind of relationship isendorsed as alone morally paradigmatic.2

Now it is important to note, first, that Gilligan herself deniesthat the justice and care orientations correlate strictly with gender.She reports that recent studies show both women and mencapable of shifting easily from one orientation to the other whenasked to do so, though it is women who are most likely to exhibita dominant care orientation - a tendency, that is, for the terms ofcare to take precedence over those of justice in their approach tomoral problems (Gilligan et ah, 1988).

Second, Gilligan claims that the justice and care orientations arenot mutually exclusive: "Like the figure-ground shift in am-biguous figure perception, the perspectives of justice and care arenot," she says, "opposites or mirror-images of one another, withjustice uncaring and care unjust. Instead, these perspectivesdenote different ways of organizing the basic elements of moraljudgment: self, others, and the relationship between them" (1987,

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The'Voice of Care' 7

pp. 22-23). I will investigate this claim critically later, because itappears to underestimate the degree of tension between the twoorientations as Gilligan describes them.

My concern in this discussion is with the implications for ethicaltheory generally, and for bioethics in particular, of Gilligan'scharacterization of these two moral orientations. It is not on theempirical status of the differences Gilligan claims to have foundbetween male and female moral reasoners that I will focus, but onthe different modes of moral judgment her work has highlighted.As Marilyn Friedman has aptly put it, "the different voicehypothesis has a significance for ethical theory and ethics whichwould survive the demise of the gender difference hypothesis. Atleast part of its significance lies in revealing the lopsidedobsession of ... contemporary theories of morality with universaland impartial conceptions of justice and rights'' (1987, p. 92).

Along these lines, I want to emphasize that we must steadfastlyreject any suggestion that women speak in one moral voice; such aclaim would be preposterous at best. And we must be wary of thetendency toward gender-essentialism that the language of genderdifference can, even unwillingly, invite.3 Moreover, we need not,in the end, deny the crucial importance of justice and rights inaffirming the wisdom and value of the voice of care. We might,that is, defend the need to retain a sturdy rights conception withinethics, but affirm at the same time the need for an ethic moredemanding than the ethic of justice - one which gives an essentialplace to 'care' through norms of character and citizenship (for allpeople), traditionally thought more appropriate for women thanfor men.

Most deeply at stake in the care-oriented challenge is theconception of the moral subject, of the capacities and skills con-stitutive of moral maturity. The question thus naturally ariseswhat implications the challenge has for ethical education, whichaims to nurture and encourage moral capacities and skills. My aimis first to set out the broad contours of the challenge and then toexplore a number of implications the challenge has for bioethicaleducation.

What are the chief criticisms leveled against the justice orienta-tion by care theorists? There are four that get to the heart of thematter, corresponding to the four points of contrast listed above.

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8 Alisa L. Carse

IMPARTIALITY AS THE MARK OF THE MORAL

Recall that a first feature of the justice perspective is its commit-ment to imparitality as the hallmark of the moral point of view(the point of view from which moral judgment is rendered, moralchoice is made). On the justice orientation, we are to refrain fromgiving special weight to our particular values and preferences,personal attributes, relationships, and situations, or for that matterto anyone else's either, in determining what morality demands.On this construal of impartiality, the benefit a course of actionmight have for me, my child, or my neighborhood, for example, isnot itself deemed relevant to the moral justification of that courseof action. The impartiality requirement, so understood, capturesthe intuition that what is morally required of one person ismorally required of any person relevantly similarly situated.Moral demands don't favor any one in particular, or any par-ticular relationship as such. We can see the relationship betweenthe impartiality requirement, so understood, and the conceptionof moral principles as abstract and universal in scope (Rawls,1972; Kohlberg, 1981).

Seyla Benhabib has called the impartial moral standpoint thestandpoint of the "generalized other" (1987, p. 163). From thisstandpoint we view every individual as an independent, rationalagent entitled to the very same rights to which we ourselves areentitled as independent, rational agents. In taking this standpoint,I might acknowledge that the other has a unique life history,particular affections, attachments, commitments, and aspirations;however, what grounds the other's moral claim on me is not anyof these particular identifying features, but the fact of his or herpersonhood itself. Thus, from the impartial point of view, I canacknowledge the other's personhood, in an abstract sense, but nothis or her distinctive identity as a person.

Now, the impartiality requirement is seen by feminist critics asmorally problematic precisely because it requires abstractionaway from the concrete identity of others and our relationships tothem. Gilligan writes: "As a framework for moral decision, care isgrounded in the assumption that ... detachment, whether fromself or from others is morally problematic, since it breeds moralblindness or indifference - a failure to discern or respond to need"(1987, p. 24). The worry is that in taking an impartial standpoint, Ibecome unable to see into the other's position, to imagine myself

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in the other's place, and thus to understand the other's concernsor needs; "the other as different from the self disappears"(Benhabib, 1987, p. 165). The care orientation champions a closeattentiveness to particularities of identity and relationship as acrucial feature of moral understanding, claiming that withoutsuch attentiveness we are, in many cases, in no position to rendermoral judgment or make a moral choice at all. The impartialobserver is disqualified rather than legitimated as a competent moraljudge (cf. Gilligan, 1984; Held, 1987; Murdoch, 1970; Ruddick,1989).

One might attempt to defend the traditional commitment toimpartiality by arguing that it is properly to be understood as ajustificational constraint, not a constraint on all moral deliberation.We might, that is, hold that impartiality is crucial to the evalua-tion and justification of moral requirements (or recommenda-tions), without thereby holding that impartially justified moralrequirements (or recommendations) always enjoin moral agents totake an impartial point of view in going about their lives (Hill,1987). Both deontologists and consequentialists have standardlyrequired that moral prescriptions be justified from an impartialstandpoint. But nothing prohibits prescriptions so justified fromacknowledging partial duties and special obligations, pertaining,for example, to people in virtue of the roles they inhabit (e.g.,physician, nurse, teacher, or governor) or the specific relationshipsin which they stand to others (e.g., spouse, parent, friend, orfellow patriot).

An adequate response to this line of thought is impossible here.Let me just say, first, that the feminist criticism of impartiality isbest understood as the claim that there is no single or privilegedjustificational standpoint in morality. If one is contemplating whatresponsibilities one has generally as a teacher to one's students oras a physician to one's patients, appeal to impartially justifiedprinciples may be illuminating and appropriate. If one is trying todecide how to respond to a particular student's truancy, or to aparticular patient's refusal of treatment, attunement to thepeculiarities of individual need and to the vagaries of cir-cumstance may be essential to sound moral judgment. The broadrequirement that we attend to the particularities of others and ourrelationships to them can itself be validated from an impartialpoint of view - one which privileges no one in particular and noparticular group or relationship as such (Sher, 1987). However, the

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justifiability of impartially justified prescriptions must be subjectto assessment with an eye to particulars. The suggestion, then, isthat impartial prescriptions cannot always inform us sufficientlyabout how to respond to others, and morally relevant features ofparticular situations will sometimes be obscured through anoverzealous reliance on impartial prescriptions, even those thatrecognize special obligations and duties. This is not to deny thatimpartial deliberation is sometimes appropriate to moral justifica-tion; it is rather to claim that the impartial point of view has nospecial authority as such in determining the moral validity of ourjudgments or the assessment of moral requirements andrecommendations.

More broadly, the rejection of impartiality as the mark of themoral is a rejection of the prevailing tendency in ethical theory toconstrue, as morally paradigmatic, forms of judgment thatabstract away from concrete identity and relational context, and toview moral maturity and skill as residing essentially in thecapacity for abstract judgment so construed. The focus on impar-tiality as the hallmark of moral judgment has had the effect ofascribing a derivative, secondary status to forms of epistemic skill- involving attention to nuance and peculiarity - that are, from theperspective of care, often of the first importance.

MORAL JUDGMENT AS PRINCIPLE-DERIVED

This first challenge to the justice orientation leads us to a second.Recall the conception of moral judgment within the justiceperspective as principled judgment. Moral conclusions aboutwhat to do in particular cases are depicted as derived fromgeneral principles or rules of conduct. The care orientation ischaracterized by a general antipathy to moral principles. At onepoint, Gilligan describes a moral judgment as "a contextualjudgment, bound to the particulars of time and place ... and thusresisting all categorical formulation'' (1982, pp. 58-59). Theresistance to principles coincides with the rejection of impartialityas a (necessary) mark of moral judgment; to act on principles isjust to act for reasons that are taken to hold with the same forcefor all others who are similarly situated. But there is some confu-sion about the nature of principles and the role principles can (andcannot) play in moral judgment. Thus, I want to try to motivatethe movement away from a conception of moral judgment as

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essentially principle-driven while in the end acknowledging areduced, but important, role for moral principles, properly under-stood.

An extreme conception of principled judgment asserts, withKant, that principles admit of no exceptions. Let us consider,however, a less extreme conception of principles according towhich they have pritna facie status, for this is the conceptiongenerally used in bioethics (cf. Ross, 1930; Beauchamp andChildress, 1989; Beauchamp and McCullough, 1984). On thisconception, no single principle is granted absolute priority incases of conflict. Rather, the weight of principles must be assessedas cases arise, and any principle can on some conditions beoverridden. On this construal of principled reasoning, anapprehension of contextual detail and a willingness to tailor moraljudgments to the particulars of context does not amount to anabandonment of principles. Quite the contrary, sensitivity tocontextual detail is necessary in order to apply principles toparticular situations.

The question thus arises, Why not maintain a conception ofmoral judgment as principle-driven, even within a care orienta-tion? The answer lies in the limited usefulness of principles ininforming and guiding a caring response. This can be seen inseveral ways.

First, there arises a general point about principle application.Recognizing that a general principle or rule is relevant to thesituation at hand, and knowing how it is fittingly to be acted uponrequires a capacity for discernment that is distinct from, andpresupposed by, the application of principles themselves. Considerthe apparently simple injunction to be kind to other people. Whatdoes meeting this injunction amount to? Being kind is no mechani-cal matter. A kind response in one situation could be an intrusiveor meddlesome response in another. Now we might generalizeabout what kind people do: kind people, for example, tend to tryto cheer up their friends when their friends are sad, to help peoplepick up the groceries they have dropped, to comfort others whoare suffering, and the like. But there are no principles or rules toguide such actions; those judging must be responsive to particularnuances of situations as they arise. Being a kind person is, amongother things, being disposed to 'see' that one's friend needscheering up or that, in this case offering a hand with the grocerieswould be helpful rather than meddlesome. To be kind is, among

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other things, to be capable of interpreting when a situation is onein which kindness is called for and what being kind amounts to inthat situation.4 An account of moral judgment according to whichit consists in the deductive application of general principles (evenprima facie ones) to particular cases does not alone provide anadequate picture of how we come properly to interpret situationsand judge what we ought to do (Nussbaum, 1985; Sherman,1990b).

Moreover, as the kindness example illustrates, it is, within thecare orientation, not just a sensitivity to the particular features ofcontext that is integral to moral judgment, but more specifically, asensitivity to other people, a capacity to perceive (as best we can)how others feel, and how they understand themselves and theircircumstances. Attention must be given to the unique and un-repeatable features of other persons, our relationship to them, andthe circumstances in which we find ourselves with them. Thisattention, and the discernment of particulars it involves, is itself amoral capacity which can be developed and exercised with greateror lesser success and which, crucially, is not itself principle-governed.

Because the injunction to give care generally requires that we beattuned in certain (caring) ways to the particular and uniquecontours of situations as they come up, and more particularly, toother people, an account of moral judgment as principle or rule-derived cannot, in an ethic of care, provide a full picture of howwe come properly to judge what we ought to do.

This is not to say, however, that there is no role for principles toplay in a care orientation; principles may prove indispensable. Forthey can help to activate virtuous perception by calling to mindbroad norms of conduct and thereby aid us in articulating at leastsome of the moral stakes of our decisions. They can also providecrucial checks on our pursuit of others' welfare. But an appeal toprinciple can not alone establish the moral validity of particularjudgments, for the appeal to principle is itself valid only insofar asdecisions based on the principle are good ones. Establishing thiswill require a discernment of the particulars (Nussbaum, 1985;Aristotle, Nichomachean Ethics 11137bl3ff. in McKeon, 1941). Andproperly discerning the particulars will require the exercise ofspecific forms of affective and cognitive skill - of emotionalattunement and sympathetic insight which are not themselvesprinciple-governed.

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This brings us to another, related point. When we 'see' that thechild crouched in the corner wants to be approached and touchedrather than called to or left alone, when we speak more softly toquell someone's fear or comfort someone in pain, or look awayfrom someone who has just been humiliated, our response to theother may be direct and dispositional rather than indirect anddeliberative. Though I may come to avert my eyes from someonethrough a process of principled deliberation, I might also avert myeyes spontaneously, in direct (non-deliberative) response to hisdistress. Similarly, I might approach and touch someone ormodulate my voice 'without even thinking'. Practically attunedresponses to situations are not always grounded in forms ofexplicit awareness or undertaken as a result of principled delibera-tion. They can be the result of practical insight that is dispositionaland non-interferential, a sympathetic attunement to others' needs orconcerns which directly informs our response to them.

This suggests that it is not only the case that principled moraldeliberation involves the exercise of discernment that is not itselfprinciple-directed, but also that principled deliberation is not itselfalways integral to generating a caring response to others.

MORAL INTELLECTUALISM

This brings us to a third feature of the feminist challenge, namely,the challenge to the intellectualism of the justice orientation and acorrelative assertion of the centrality to the moral personality ofwell-cultivated emotion. This general challenge raises complexand highly controversial issues which I can only touch on here. Itis useful to understand the challenge as having two dimensions:the first concerns the importance of the emotions to moral discern-ment; the second concerns the importance of emotion, and inparticular, the expression of emotion, to moral response(Nussbaum, 1985, esp. pp. 183-193; Sherman, 1990a, 1990b).

How are the emotions important to moral discernment? Thesuggestion is that it is often through our emotions that we discernthe condition of others; insight into the feelings and concerns ofothers is not a deliverance of the intellect alone. Our own capacityfor humiliation can, for example, tune us in to the fact thatsomeone else is being humiliated, rather than merely ribbed orteased. Through empathy or compassion, we may recognize

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another's pain or discomfort, even when its manifestations aresubtle or masked. Similarly, anger, suprise, anguish, fear, embar-rassment, grief, joy, yearning, and sympathetic versions of these,are ways of being attuned to situations, modes of attention, in virtueof which certain features of a situation stand out for us and othersrecede from our attention.

To view the emotions, as they often are viewed in ethicaltheory, as agitations or disturbances of moral judgment - messyencumbrances of the moral self that need not concern us so longas they are kept subject to the control of a rational will - is tooverlook the crucial role emotions can play, when properlycultivated, in alerting us to morally salient dimensions of situa-tions (Murdoch, 1970; McDowell, 1979; Blum, 1980).

In addition to their role in moral discernment, the emotionsplay an important expressive role in moral response. As theexample of kindness illustrates, it is not just what we do, but alsohow we do what we do, that can make a moral difference in givingcare; and this is reflected in our gestures, our tone of voice, whereand how we stand or move, how we listen - crucially, the emo-tions we do (or don't) express. Expressing the right emotions atthe right time in the right way is, on this view, an integral featureof moral agency (Aristotle, Nicomachean Ethics 1106b21-23 inMcKeon, 1941). It is important to distinguish this point from theclaim that we ought to act out of good motives, out of interest andconcern for the other. The emotional quality of our response toanother is not just a matter of the motivation out of which we act;it is also a matter of the manner in which we act. This is an impor-tant distinction, for the treatment of emotion in ethics is stan-dardly confined to an assessment of the motives of action. Yet itcan be morally significant not just that one acts, for example, fromsympathetic, considerate, or kind motives, but that one actssympathetically, considerately, or kindly, that is, in such a way asto express sympathy, consideration, or kindness in acting(Sherman, 1990b).

It appears, then, that we are not simply in need of an enrichednormative vocabulary in terms of which to address those skillsand capacities agents require in order effectively to apply generalprinciples or rules of conduct to particular cases. We are also inneed of an account of those skills and capacities agents need inorder effectively to discern what morality demands, encourages, orrecommends and, having done so, to conduct themselves in the

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proper manner, to express themselves effectively and ap-propriately.

Thus, it is clear that the emphasis on impartial, principled, anddispassionate judgment that marks the traditional justiceorientation will fall short of providing adequate guidance withinan ethic of care. A key element of the care orientation in ethics, asthe philosophical analysis of care is further developed, will needto be an account of the skills and character traits - the virtues -which constitute the caring person. Insofar as care theory infusesbioethical theory, more attention will need to be given in bioethi-cal theory to the virtues relevant to caretaking within medical andnursing practice. And among the virtues will be certain cultivatedemotional capacities.

MODELLING OUR RELATIONSHIPS

Let us turn now to a fourth feature of the justice orientation towhich the challenge of care theory has been directed, namely, theemphasis within this orientation on norms of formal equality andreciprocity in treating the morality of human relationships.Annette Baier writes,

It is a typical feature of the dominant moral theories and traditions, since Kant,or perhaps since Hobbes, that relationships between equals or those who aredeemed equal in some important sense, have been the relationships that moralityis concerned primarily to regulate. Relationships between those who are clearlyunequal in power, such as parents and children, earlier and later generations inrelation to one another, states and citizens, doctors and patients, the well and theill, large states and small states, have had to be shunted to the bottom of theagenda, and then dealt with by some sort of 'promotion' of the weaker so that anappearance of virtual equality is achieved. Citizens collectively become equal tostates, children are treated as adults-to-be, the ill and dying are treated ascontinuers of their earlier more potent selves, so that their 'rights' could be seenas the rights of equals (1987a, p. 53).

The commitment to equality can sometimes be indispensable inensuring that those more vulnerable and less powerful areprotected against forms of harm, for example, exploitation orneglect. But as Baier notes, this commitment also covers over,'masks', the nuances of those relationships between people ofunequal power or one-sided dependence, and the special moraldemands weakness or dependency can introduce into arelationship:

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A more realistic acceptance of the fact that we begin as helpless children, that atalmost every point of our lives we deal with both the more and the less helpless,that equality of power and interdependency, between two persons or groups, israre and hard to recognize when it does occur, might lead us to a more directapproach to questions concerning the design of institutions structuring theserelationships between unequals (families, schools, hospitals, armies) and of themorality of our dealings with the more and the less powerful (1987a, p. 53).

The relative weight given to relations among 'equals' has led tosilence in moral theory about good and bad kinds of engagementin relationships characterized by material inequality - of power, ofknowledge, of vulnerability (as with the sick or young or depend-ent).

This criticism is related to a second, directed to the rights-basedmodel of moral relationship and the individualistic conception ofthe self. In particular, the centrality of the right to non-interferencein many justice models is based in a commitment to the value ofautonomy, and thus of social frameworks within which in-dividuals are ensured the liberty to pursue their (autonomouslyaffirmed) conceptions of the good, consistent with the equalliberty of others. On this view, if you have a right to something,then I have the duty not to impede your pursuit of it. In meetingthis requirement, I respect your right to non-interference and Ihave a legitimate right to demand that you will respect mine. Ourinteractions are thus marked by a norm of mutual non-interference. What does the emphasis on individual autonomyand the right to non-interference have to do with the individualis-tic conception of the self? What objections have been raisedagainst these features of the justice orientation?

One worry is that a moral model of our relationships whichconstrues them as paradigmatically structured by rights to mutualnon-interference, except when more robust association has beenvoluntarily assumed, can address very few of our relationships.Just as detachment was seen, from the perspective of care, tothreaten us with moral blindness, so non-interference is seen, fromthe perspective of care, to threaten us with neglect and isolation,especially if we are dependent or relatively powerless, like thevery young, the very old, or the sick.

This brings us back to the individualism of the self on the justiceperspective. On this perspective, it isn't assumed that we are inrelationship, or that human relationship per se has value. Theexistence and value of particular relationships and of human

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relationship more generally are treated as resting in individualchoice. Relationships are construed as among the autonomouslyaffirmed goods we are, as individuals, to be at liberty to pursue.

Now we do, as individuals, choose some of our relationships.We tend, for example, to choose who (if anyone) we will marry ordivorce; we sometimes choose friends and often choose the clubswe join. But many of our relationships, and more importantly, ofour caring relationships, are not undertaken through choice: wedon't choose our parents or siblings, nor do they choose us; andthough we might choose to have children, we don't choose thechildren we have. This holds true of many of our students andpatients as well. And though we can reflect critically on the termsof our relationships - how we relate to others or they to us - wecan not, as individuals, independently choose or dictate theseterms. Relationships require flexibility and responsiveness on thepart of those in the relationship.

Gilligan writes: "As a framework for moral decision, care isgrounded in the assumption that the other and self are interdepen-dent" (1982, p. 24); that a good life is one which involves a"progress of affiliative relationship" (1982, p. 170); that "'theconcept of identity ... includes the experience of interconnection"(1982, p. 173; cf. Baier, 1987a, 1987b; Bishop, 1987; Ruddick, 1984,1989). A more adequate moral model of us as individuals wouldmore realistically recognize the full extent of our mutualinterdependence; it would attend more actively to modes of relatingto and being with others that help to sustain good relationshipsamong individuals who are not equal in power and relativedependence (cf. May, 1977,1983; Pellegrino and Thomasma, 1988).

THE ETHIC OF CARE

Where do these criticisms, if taken seriously, point us? The carecritique has both methodological implications, for the process ofmoral reasoning and judgment by which we are to come tounderstand what morality demands of us, and normative implica-tions, for what it is that morality demands of us.

On the methodological front we have seen that 'care' reasoningis concrete and contextual rather than abstract; it is sometimesprinciple-guided, rather than always principle-derived, and itinvolves sympathy and compassion rather than dispassion. Thisintroduces a conception of moral psychology much thicker and

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richer in its skills and capacities than the conception needed onthe justice perspective and suggests a movement in a more virtue-theoretic direction, in which not only our actions, but also ourcharacters, are a focus of moral attention.

On the normative front, we have seen that the ethic of careasserts the importance of a concern for the good of others and ofcommunity with them, of a capacity for imaginative projectioninto the position of others, and of situation-attuned responses toothers' needs. We have also seen moral importance extended fromwhat we do, to how we do what we do - the manner in which weact, where this includes the emotional quality or tone of ouractions as integral to moral response. Finally, we have seen a callfor more moral acknowledgement of our mutual interdependence,of the actual limitations of material equality, and of the specialresponsibilities vulnerability and dependence can introduce intoour relationships.

Both the methodological and normative implications of the carecritique suggest that the differences dividing the two perspectivesconcern much more than emphasis; they concern our conceptionof the most fundamental elements of moral life: moral judgment,the nature of the moral self, and our responsibilities as individualsto each other.

There are strong theoretical precedents for the care perspective,so understood. A historical alternative to the deductive, principle-driven account of moral judgement is found in Aristotle, forexample, for whom moral deliberation involves practical wisdom,which is understood to outrun any general rules or principles onemight possibly devise (Nichomachean Ethics 1104al-9 in McKeon,1941). Moreover, Aristotelian virtue consists in dispositions topassion as well as action, feeling the right emotions "at the righttimes, with reference to the right objects, towards the right people,with the right motive, and in the right way" (Nichomachean Ethics1106b21-3, 1109b30 in McKeon, 1941). The care orientation alsofinds a kindred spirit in David Hume, who criticizes Hobbes andLocke for what he calls their "'selfish systems of morals" and whoviews corrected sympathy, not principled reason, as our basicmoral capacity (Baier, 1987b).

BIOETHICS AND EDUCATION

I want, in this section, to identify some implications for bioethics

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and education of the preceding challenges to the justice orienta-tion in ethical theory. There are some clear affinities betweenstandard approaches taken in bioethics and the justice orientationthat care theorists characterize. Bioethical theories tend to take aprinciple-based approach on which moral judgments are con-strued to be directed paradigmatically to the question "Whatought morally to be done?" and thus to be concerned primarilywith right action, rather than good character or virtue. Bioethicaltheories tend largely to emphasize, as fundamental, the impartialprinciples of respect for autonomy, justice, and beneficence. Muchcurrent debate in bioethics is between deontologists andutilitarians, and concerns how we are to understand and rank theimportance of these principles.

It is true that the importance placed on beneficence in somebioethical theories may seem to make these theories morally richerthan the justice orientation challenged by care theorists. For theprinciple of beneficence requires us to do more than recognizeothers' rights to non-interference; it requires us actively topromote the welfare of others. Nonetheless, there is a notabledifference: the care orientation emphasizes sympathy and compas-sion as modes of concerned attention to concrete and particularothers, whereas the principle of beneficence urges a love ofhumanity7, an abstract concern for others in virtue of our commonhumanity.5

The fact that case studies are a central focus of bioethicaldiscussion, that discussions of standard bioethical issues such aseuthanasia, confidentiality, informed consent, or resource alloca-tion often involve paying attention to the concrete details ofparticular contexts in which those issues arise, may reinforce in asecond way a sense that there are strong similarities betweenstandard bioethical approaches and the ethic of care. It is impor-tant to emphasize, therefore, that while bioethics discussions, invirtue of focusing on applied issues, tend to be more concrete thansome discussions in theoretical ethics, standard bioethical ap-proaches continue to be abstract in a crucial sense: they rely on alanguage of abstract rights and principles, and on conceptions ofobligation formulated independently of particular contexts.Details of context are consulted only in order to apply abstract,general principles to particular cases.

The care-oriented challenge thus has implications for the ethicaltheory taught, the issues addressed, and the skills and sensitivities

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encouraged through bioethical education. Let me set out sevenimplications here, as suggestions for further discussion andinquiry.

1. One issue the care-oriented challenge raises for bioethicaleducation is the possible tendency of a bioethical approach thatpictures moral judgment as essentially principle-driven to em-phasize institutionally developed rights-based codes and proce-dures and to underemphasize the personal skills and capacitiesthat go into good caretaking. Too much rule-dependence may runthe risk of encouraging a courseness of feeling and a lack of careand compassion necessary to fostering hope and ensuring that apatient's good is served in the healing process.

An example of a change in bioethics which is a change in thedirection of an ethic of care, is found in more recent treatments ofthe issue of informed consent - in particular, the shift away froman emphasis on institutional rules of information disclosuretoward greater attention to the quality of the patienfs understand-ing and of the communicative exchange. What this shift in em-phasis demonstrates is that in a properly caring context, respectfor autonomy - the principle which grounds informed consent,will involve not only negative prohibitions against coercion,manipulation and the like, but also positive duties, to nurture andsustain the patient's capacity to exercise autonomous choices. Thisprocess requires much more than procedurally correct forms ofinformation disclosure; it requires sensitivity to the individualpatient - to his or her fears, hopes, values, and capacities in thedecision-making process (cf. Faden and Beauchamp, 1986, esp.,Chapter 7; Beauchamp and Childress, 1989, esp., Chapter 3;Pellegrino and Thomasma, 1988).

2. This suggests that more effort should be made to attunestudents to their own and others' values, fears, capacities andcommitments, and to encourage the consideration of such factorsin the interpretation and resolution of ethical conflicts. Alongthese lines, the care-oriented challenge raises the question foreducators how we can, through education, widen and expandemotional knowledge and imaginative power, and encourage inour students the capacity to enter into the feelings andperspectives of others. Iris Murdoch recommends the study ofliterature as a way to learn to "picture and understand humansituations'7 (1970, p. 34). A bioethical education might includeexposure, through readings, testimonials, and films to the health

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care problems and healing practices of different cultures,religions, and peoples, thereby enhancing students' awarenessand sensitivity to others. It might also provide examples of real orfictional people who can inspire or serve as role models, andencourage discussion of both these particular lives and of culturalideals.

3. On the care orientation, what is sought in ethical debate is notso much theoretically neat, universally justifiable solutions tomoral conflicts as shared interpretations of problems and collec-tive success in mediating and balancing the different moral claimsand concerns various parties to a case express. If we accept thispicture of moral conflict-resolution, more emphasis would need tobe placed in bioethical education - particularly of those who willwork in the clinical setting (such as physicians, nurses, clinicalethicists, and the like) - on the development of communicationskills. We need to ask ourselves as educators what sorts of skillsfacilitate people in expressing themselves and listening to others,in interpreting what others say or do with insight and understand-ing. We might pay more explicit attention to the implications ofmanner, tone, forms of demeanor and expression - for the abilityto communicate effectively.

4. A broad implication of the care-oriented challenge - par-ticularly the worries voiced about impartiality - is that bioethicalissues ought not to be addressed in a social and political vacuum.Bioethical education should encourage critical reflection on thegender patterned occupational roles among health care providers,on the way in which the roles of physician and nurse, for example,have historically been construed as male and female roles, respec-tively, and on the effect this has had on the division of labor andauthority in health care practice (cf. Warren, 1989, p. 77; Winslow,1984). This becomes particularly important as more women entermedicine and the nursing shortage becomes an ever greaterproblem. Bioethical education should also include an examinationof the broad social and economic implications of particularmedical practices and technologies, such as reproductive tech-nologies, and address the implications both for our access tohealth care and for our health care needs of factors such as age,gender, class, religion, and sexual orientation (Overall, 1987; 1989,p. 182; Sherwin, 1987, 1989). Ignoring these factors in our ethicalreflections can desensitize us to the very real differences in thehealth care needs particular individuals and groups face.

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22 Alisa L. Carse

5. Related to this point, more attention might be paid to thenature and dynamics of particular relationships and relationship-types as significant feature of ethical analysis. The interpretationof cases can involve an acknowledgement of the inequalities ofdependency, vulnerability, and knowledge within the relation-ships that actually structure our lives. Recognition of the ine-qualities and articulation of the positive duties of care and em-powerment they introduce can be an important dimension ofbioethical analysis. Students might be encouraged to reflect onvarious normative models of human relationship that have beenproposed in the bioethical literature (e.g., the contract model, thecovenant model) and their suitability given the different forms ofinterdependency and responsibility that characterize relationshipsbetween patients and health care providers.6

6. Bioethical education must, in the end, affirm the very realmoral ambivalence often experienced by all of us, especially bythose who wield power in helping others, and guide students inlearning to cope constructively with their own and others' sourcesof moral ambivalence through open dialogue, role-playing, andessay and journal writing (Warren, 1989, p. 84). Along these lines,the scope of moral discourse might be self-consciously andexplicitly expanded to include not only what is morallyobligatory, but also what is recommended, urged, advised, orencouraged by morality. Invoking a richer moral psychologicalvocabulary and paying greater attention to contextual peculiarityand social-economic patterns in our analyses of cases and issues,can facilitate the process of articulation and analysis in a way thatremains true to the intricate moral and psychological stakespresent.

7. Finally, what becomes clear is that from the perspective of thecare orientation, moral maturity involves a wide range of percep-tual, imaginative, emotional and expressive capacities. Thissuggests that bioethical discussions should be addressed not onlyto the question "What is the moral status of this action (or policyfor action)?" but also "What kind of person ought I to be?" and"What traits and capacities ought I to develop?". As we have seen,this introduces the need for a richer moral vocabulary, for theability to address issues of character and virtue as well as rightaction. But it also suggests that bioethical education would, at itsbest, be aimed at developing not only intellectual skills and moraltheoretical knowledge but the whole character of the moral agent.

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It would itself be a kind of "fitness program" (Solomon, 1988,p. 437) intended to sharpen verbal tools and analytical skill butalso to foster moral virtue.

CONCLUSION

There are, of course, many worries that might be raised for thecare orientation in the context of bioethics. Let me look at threethat are particularly germane to the present discussion.

It might, first, be objected that there are important moral issueswhich fall outside the reach of an ethic of care, even if it is caringthat leads us to be concerned about them. The worry is that anethic of care will have nothing to say about certain forms ofinjustice, that we might, as Virginia Held has put it, "decide thatthe rich will care for the rich and the poor for the poor, with thegap between them, however unjustifiably wide, remaining what itis" (1987, p. 120). It is important to stress, first, that what is inquestion in the challenge we have reviewed is not the importanceof justice but the sufficiency of justice and the primacy that hasbeen granted the justice orientation in moral theory. An adequatemoral theoretical approach may well involve an integration of thejustice and care orientations so as to retain their respectivestrengths through rehabilitated notions of 'justice' and 'care'.

Second, there might be a perceived need for detachment on thepart of good physicians and nurses that is incompatible with theemphasis on compassion and sympathy on the care orientation.As Beauchamp and Childress write: "A physician who lackedcompassion would generally be viewed as deficient; yet compas-sion also may cloud judgment and preclude rational and effectiveresponses. Constant contact with suffering can overwhelm andeven paralyze a compassionate physician" (1989, p. 383). Theimportant point to make in response to this worry is that there isnothing intrinsic to the care perspective which excludes ap-propriately detached forms of concern and compassion. A goodhealth care professional should be able to summon the ap-propriate degree of emotional detachment, or equanimity, whenthis is crucial to serving the well-being of the patient.

The third difficulty concerns the possible tendency of an ethic ofcare to allow, on the one hand, too much self-sacrifice on the partof the health care professional, and on the other, overzealouscaretaking, leading to too much involvement with patients, or to

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24 Alisa L. Carse

paternalism. In response, let me note first that a full account of thevirtues of caretaking would need to spell out conceptions ofproper self-regard - or care for oneself - as protection against self-effacement or problematic self-denial and as a precondition ofsound caring for others (cf. Ruddick, 1984, pp. 217-218; Gilligan,1982, p. 149). Secondly, it is important, in light of worries aboutpaternalism, to build into our very conception of caretaking therequirement that the caretaker respect the person cared for.7 Aprincipal aim of a medical ethics informed by an ethic of carewould need to be to address how our institutions and practices ofhealth care can further empower patients and in general en-courage more active participation on the part of non-experts intheir own health care. This would involve a critical exploration oftraditional construals of medical authority and reflection on theeffects of power dynamics within 'healing' relationships (cf.Warren, 1989, p. 81; May, 1983).

In conclusion, we are still in need of a clear and systematicaccount of the modes of feeling, of thought, and of action thatcharacterize the care orientation. And we still need to articulate aclear set of standards by which we can distinguish morally goodfrom morally problematic (or even morally debased) forms of'care7. We also have a need for boundaries which exclude concep-tions of care that serve to justify relations of domination andsubordination or which threaten to bolster, rather than to chal-lenge, existing forms of gender division and stratification.

But the strength of the care-oriented approach lies in its mostbasic recommendation: that we reflect upon the moral voicesemployed in health care practice and bioethics - the values andideals that are highlighted, the forms of discourse used, and themodels and paradigms that are central to attempts to make senseof medical and moral questions which arise. That challenge urgesthat we become self-conscious about how the dominant modelsshape our conception of what morality demands and invites us toquestion the assumption that there is only one legitimate mode ofmoral reasoning, only one moral voice. That challenge suggeststhat part of our job in coming to understand our moral world willinvolve coining to be reflective about the voices in which weourselves speak and to listen to and learn from the voices ofothers. These skills can be made an integral part of a bioethicaleducation.8

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NOTES

1 A complex and important question that I cannot go into here is whether and towhat extent Kantian and contractarian theories, generally constituting the targetof attack in this feminist movement, can accommodate the care orientation. Myown position is that they can to some extent, but not fully. Whatever position onetakes on this issue, however, one thing remains true: the focus of traditionaltheories rooted in Kant and the contractarians is quite different from that of thecare orientation. I hope that my discussion suggests some ways in which thedifference is not one of focus alone.2 This is not to say that all de facto relationships are morally acceptable on thecare orientation; the care orientation can be understood as striving, among otherthings, to articulate norms of relationship that more adequately acknowledge thebroad facts of human interdependency.3 Though we must reject the suggestion that there is a distinctive voice that iswoman's as such, we might understand this recent project in feminist ethics asunveiling - making visible and explicit - in our ethical theories and ethicalpractices one of the important moral orientations emerging out of women'sdistinctive experiences in our society, given the sexual division of labor and thesocial significance of gender generally as it affects identity-formation. Thisproject does not, however, affirm the care orientation as most appropriate forwomen; quite the contrary, it affirms its importance in general - for women andmen - and thus highlights forms of moral skill and moral maturity that havebeen overlooked or granted only secondary status in many of our preeminentethical theories.4 This is not to deny that uncaring people or scoundrels can on occasion showgenuine kindness for others. It is to suggest that being concerned about others'well-being, being a kind person, is a condition for having the required sensitivityand sympathetic insight into others that is a further condition of effectivelypromoting others' well-being in general.5 A notable exception is found in the treatment given the principle ofbeneficence by Pellegrino and Thomasma (1988).6 William May (1977,1983) recommends that the relationship between the healthcare provider and the patient be viewed as a covenant rather than a contract,because it lacks a specific quid pro quo. Warren Reich (1987) argues that contractmodels and rights language are "too adversarial" and fail adequately to capturethe need for "acceptance, trust, affection, and care" which can in effect constitutethe moral status of others within relationships. He emphasizes the need toencourage bonding and loyalty to those in need of care, not just respect forrights. Pellegrino and Thomasma (1988) explore the limitations of contractualmodels of relationship in medical ethics, stressing the unequal power andvulnerability introduced through illness. Annette Baier (1986) recommends that alanguage of trust and anti-trust be introduced into our ethical reflections tosupplement if not supplant contract models. All of these proposals and othersmight be critically evaluated and contrasted with standard contractual models.

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7 Pellegrino and Thomasma (1988) develop an account of beneficence whichinvokes, as an integral part, respect for the autonomy of the one whose good isserved.8 An early version of this paper was first presented in the Intensive BioethicsCourse at the Kennedy Institute of ethics at Georgetown University in June 1989.I am grateful to those present in the audience for their challenging questions. Inaddition, I am especially indebted to Tom Beauchamp's helpful comments andsuggestions on an earlier draft of this paper.

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Documents

THE 'VOICE OF CARE': IMPLICATIONS FOR BIOETHICAL EDUCATION